Dementia is a progressive condition that causes gradual decline in cognitive functions like memory, language, reasoning and judgement. In most cases, the symptoms get worse slowly over several years. However, some people with dementia experience a sudden worsening of symptoms, which is referred to as acute exacerbation.
What is acute exacerbation of dementia?
Acute exacerbation or acute worsening of dementia symptoms happens when there is a sudden and significant decline in the person’s cognitive abilities and day-to-day functioning over a short period of time, usually days to weeks. The person’s confusion, disorientation and inability to perform routine tasks increases markedly.
Some common signs and symptoms of acute exacerbation of dementia include:
- Marked decline in memory and recall
- Increased disorientation and confusion
- Wandering, restlessness and agitation
- Difficulty recognizing family members
- Inability to follow instructions or conversations
- Problems with communication and language
- Personality changes, suspiciousness or paranoia
- Hallucinations and delusions
- Difficulty performing daily living activities like dressing, eating, bathing
If such symptoms appear suddenly and worsen noticeably over a few days or weeks, it is considered an acute exacerbation of dementia.
What causes acute worsening of dementia symptoms?
There are various potential causes for the sudden deterioration of dementia symptoms. Here are some of the common reasons:
Infections
Infections, especially urinary tract infections and pneumonia, are a leading cause of acute exacerbation in people with dementia. The infection causes inflammation, fever and increased confusion. Dehydration from fever and infection can also worsen mental status.
Medication interactions
Reactions between different medications or side effects of new medications can trigger acute worsening of dementia symptoms. Certain antibiotics, benzodiazepines, opioid painkillers, anticholinergics and cardiac medications are common culprits.
Metabolic abnormalities
Electrolyte imbalances and disorders like hypoglycemia (low blood sugar), hypercalcemia (high calcium), and hepatic encephalopathy can quickly worsen confusion and neurological symptoms.
Pain
Untreated or undertreated pain, especially from conditions like arthritis, bone fractures and internal injuries can cause acute exacerbation in dementia patients. The pain causes distress and disorientation.
Delirium triggers
People with dementia are at high risk for delirium – a temporary condition caused by an acute medical illness, surgeries, injuries or medication effects. Delirium leads to worsening restlessness, agitation, confusion and hallucinations.
Stroke
Vascular dementia caused by strokes or mini-strokes can deteriorate suddenly when more brain damage occurs due to a new stroke or cerebrovascular event.
Head injury
Even minor head trauma from falls or accidents can worsen dementia temporarily. More severe head injury can worsen it permanently.
Nutritional deficiencies
Deficiencies of vitamins and nutrients like B12, folate and iron due to inadequate diet can exacerbate dementia symptoms.
Caregiver absence
When familiar caregivers are absent for some time, it can disorient the person and lead to worsening behavioral issues and confusion.
Hospitalization
Admission to the hospital for any illness or surgery can worsen confusion significantly, especially if adequate care is not provided to orient the patient.
Sleep disturbances
Disrupted nighttime sleep can trigger next-day episodes of increased confusion, anxiety and agitation in dementia patients.
Medication noncompliance
Interrupting dementia medications abruptly, forgetting to take them, or mixing up doses can all exacerbate symptoms.
Environmental stress
Heat waves, cold weather, loud noises and other environmental stressors may worsen behavioral and neurological symptoms.
Life changes
Major life changes like moving homes, switching caregivers, loss of family member or pet, or disruption in routines can trigger worsening dementia temporarily.
Is acute exacerbation preventable?
While the progressive course of dementia cannot be stopped, some basic precautions and care measures can help prevent episodes of acute exacerbation and deterioration of symptoms. These include:
- Treating infections early
- Avoiding delirium by reorienting and keeping routines
- Ensuring medications are reviewed for interactions and side effects
- Managing pain optimally
- Providing hearing and visual aids if needed
- Having regular medical check-ups to identify treatable causes
- Following the prescribed treatment plan and therapies
- Maintaining hydration and nutrition
- Providing comfortable and supervised environment
- Minimizing noise and disruptions as possible
When to seek emergency help for worsening dementia?
Call emergency services or take the person to an ER immediately if they show any of the following symptoms:
- Sudden severe confusion, disorientation
- Unable to walk or get out of bed
- Unable to respond or communicate at all
- High fever
- Difficulty breathing, shortness of breath
- Chest pain, tightness
- Sudden weakness or inability to move a body part
- Head injury from a hard fall
- Seizure
- Loss of consciousness
These require prompt emergency medical care to identify and treat potentially life-threatening conditions like infections, heart problems, strokes or injuries.
Tests and evaluation of acute worsening of dementia
When a person with dementia experiences sudden significant decline in their condition, doctors will carry out investigations and tests to determine the possible reasons behind it. Some common evaluations include:
- Physical exam – To check for signs of infections, pain, injury
- Blood tests – To detect infections, electrolyte imbalances, kidney or liver problems
- Urinalysis – Checks for UTI which can worsen confusion
- Neurological tests – For stroke, seizure disorders, delirium
- CT scan – Looks for brain bleed, injury, hydrocephalus
- MRI – Helps find strokes, tumors, evidence of dementia
- Lumbar puncture – For checking proteins and cell counts to diagnose infections, bleeding or dementia
- EEG – Records brain wave patterns and electrical disturbances
- Neuropsychological evaluation – Assesses attention, memory, reasoning, language
- Depression screening – Mood disorders may worsen cognition
- Medication review – Looks for side effects, interactions causing problems
Based on the results of these investigations, underlying factors like infections, metabolic issues, adverse drug effects or cerebrovascular causes can be identified and treated.
How is acute exacerbation of dementia treated?
The main goals of treatment for sudden worsening of dementia symptoms are:
- Identify and treat underlying causes like infections, dehydration, strokes etc.
- Manage behavioral symptoms like agitation, hallucinations, wandering
- Ensure safety and prevent falls or injuries
- Provide supportive care for better recovery
The different treatments used include:
Medications
- Antibiotics for infections
- IV fluids or hydration support for dehydration
- Nutritional supplements if deficient
- Adjusting diabetes or heart medications if needed
- Stopping problematic medications
- Starting psychiatric medications for severe agitation, anxiety, hallucinations on a short-term basis
Supportive care
- Close monitoring of food intake, bowel and bladder function
- Assisting with walking and use of assistive devices to prevent falls
- Providing frequent orientation and supervision
- Maintaining schedules and familiar routines when possible
- Providing adequate pain relief through medication, physiotherapy, or other therapies
- Trying non-drug approaches like music, aromatherapy, massage for agitation
- Engaging in structured activities to stimulate cognition
In severe cases, temporary hospitalization may be required for close monitoring, managing unsafe behavioral symptoms, or administering IV medications.
What is the prognosis after acute worsening of dementia?
The prognosis after an acute exacerbation episode depends on:
- Severity of the initial symptoms
- How quickly treatment was started
- Age and overall health of the person
- Cause of the exacerbation
- Presence of advanced dementia prior to the episode
In many cases, if the underlying cause is treated promptly, the person can recover close to their prior level of function within 4-12 weeks. However, some people may take longer time to improve or have residual symptoms.
With severe exacerbations or when left untreated, worsening confusion can become permanent. New loss of brain function may manifest as:
- Progression in the stage of dementia
- Worsening memory and cognitive deficits
- Increase in behavioral problems
- Ongoing disorientation and functional impairment
- Permanent loss of independent living skills
Unfortunately, episodes of acute exacerbation indicate progression of the underlying dementia. Multiple such episodes increase the rate of deterioration over time.
| Better recovery | Poorer recovery |
|---|---|
| Younger age | Very old age |
| Mild dementia stage | Advanced dementia |
| Reversible causes like UTI, dehydration | Fixed causes like strokes, brain damage |
| Early treatment | Delay in treatment |
| Absence of prior episodes | Multiple past episodes |
| Good physical health | Frailty, co-morbidities |
| Supportive care | Lack of caregiving support |
Conclusion
Acute exacerbation or sudden worsening of dementia symptoms does happen in some cases due to factors like infections, metabolic issues, medications, strokes etc. Prompt diagnosis and treatment of the underlying cause along with supportive care can help stabilize the person initially. However, such episodes tend to signify progression of the dementia. Seeking emergency help for sudden severe decline in cognition or function is crucial. With repeated exacerbations, the damage may become irreversible, warranting full-time supervised care. The overall prognosis depends on age, dementia stage, health status and cause of the acute episode.